The Inquiry’s Conclusion
Institutions are made of people, and people can be required to answer.
Inquiry || Justice || Medical Board || Conclusion
The regional medical board’s inquiry into the Coldmoor Psychiatric Institute concluded in May and produced a report of two hundred and thirty-four pages that was published in full — a decision that was itself significant, since it would have been easier, as Haas told her in a call the afternoon before publication, to publish a summary. Publishing in full was a choice that said: we are not managing the scope of this. We are showing you the scope of this. We are letting the scope be the scope. She read the full report over two days, annotating her copy with the professional attention of a colleague reading someone else’s excellent work and recognising throughout it the Bruck report, Irene’s testimony, Carey’s wall-writing, Holl’s nineteen-year list, her own green notebook and formal submission — all of it woven into the inquiry’s findings with the care of investigators who had understood that the evidence before them was exceptional and had treated it as such. The findings were unambiguous: systematic and long-term harm to patients through an unauthorised methodology; deliberate falsification of clinical records; unlawful detention of a colleague; failure of oversight at multiple institutional and regulatory levels over a minimum of fourteen years. The recommendations were similarly unambiguous and went beyond Coldmoor specifically to the structural conditions that had permitted Coldmoor specifically — the gaps in oversight, the self-reporting mechanisms that were inadequate to institutions with directors of Voss’s particular professional authority, the absence of independent patient advocacy in closed facilities. She read the recommendations and thought that some of them would be implemented and some of them would not, and that the ones that were not would eventually produce another Coldmoor in some form, because the conditions that permitted Coldmoor were not eliminated by a report that described them but by the ongoing, effortful work of people who refused to accept that what the report described was inevitable. She thought: that is also the work. That is another form of the work. She picked up her pen. She wrote to three colleagues on the medical board who she knew were in positions to advance specific recommendations. She wrote clearly and in detail and with the patient persistence of someone who has learned that the difference between a recommendation and an implementation is the work that happens between them, and that the work is worth doing, and that she is prepared to do it for as long as it takes, which is probably longer than she would prefer but not longer than she is capable of.